Workers’ compensation in North Carolina involves forms, and there is no way around it. Most cases begin with the injured employee filing a Form 18 notice of injury, while the employer or their insurance company files a Form 19. Claims can be accepted by Form 60 or 63, or denied by Form 61. A form 18M keeps medical treatment open. NC workers’ compensation forms are also used under NC workers’ compensation law for permanent disability ratings, travel expenses, to request a hearing, to terminate payment, to resume payment, to show a payment was made, and for just about everything else. Forms and NC Workers’ Comp Law go hand in hand, so learn to use them to your advantage.
The NC workers’ compensation forms are available on the North Carolina Industrial Commission’s website, but be careful filling out these forms. A NC workers’ compensation claim can be lost when a form is filled out improperly or not filled out at all.
This is a list of the forms injured workers will see most often:
- Form 18 — Notice of Accident With Instructions
- Form 18M — Request for Additional Medical Compensation
- Form 19 — Employer’s Report of Injury to the NCIC
- Form 21 — Agreement for Compensation for Disability
- Form 22 — Statement of Days Worked & Earnings of Employee
- Form 23 — Application to Reinstate Payment of Disability Compensation
- Form 24 — Application to Stop or Suspend Pmt. of Compensation
- Form 25C — Authorization for Rehab Professional to Obtain Medical Records of Current Treatment
- Form 25N — Notice of Assignment of Rehabilitation Professional
- Form 25R — Evaluation for Permanent Impairment
- Form 25T– Itemized Statement of Travel Charges
- Form 26 — Supplemental Agreement as to Payment of Compensation
- Form 26A — Employer’s Admission of Employee’s Right to Permanent Partial Disability
- Form 26D — Agreement for Payment of Unpaid Compensation in Unrelated Death Cases
- Form 28 — Return To Work Report
- Form 28B — Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation
- Form 28C — Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid Pursuant to a Compromise Settlement Agreement
- Form 28T — Notice of Termination of Compensation by Reason of Trial Return to Work
- Form 28U — Employee’s Request That Compensation Be Reinstated After Unsuccessful Trial Return to Work
- Form 29 — Supplemental Report to Form 19 for Fatal Accidents
- Form 30 — Agreement for Compensation for Death
- Form 30A — Notice of Award
- Form 30D — Award Approving Agreement for Compensation for Death
- Form 31 — Application for Lump Sum Award
- Form 33 — Request That Claim Be Assigned for Hearing
- Form 33R — Response to Request That Claim Be Assigned for Hearing
- Form 36 — Subpoena for Witness
- Form 42 — Application for Appointment of Guardian Ad Litem
- Form 44 — Application for Review
- Form 60 — Employer’s Admission of Employee’s Right to Compensation
- Form 61 — Denial of Workers’ Compensation Claim
- Form 62 Notice of Reinstatement or Modification of Compensation
- Form 63 — Notice to Employee of Payment of Compensation Without Prejudice or Payment of Medical Compensation Without Prejudice
- Form 90 Report of Earnings
- Form MSC3 Order for Mediated Settlement Conference
- Form MSC4 Designation of Mediator
- Form MSC5 Report of Mediator
- Form MSC8 Mediated Settlement Agreement
- Form T-44 Application for Review
For a free consultation with a North Carolina Board Certified Workers’ Compensation Specialist about NC workers’ compensation forms and NC workers’ comp law or any other NC workers’ compensation issues, please call or send us an email.
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